Cecily Zamora
HIV, or human immunodeficiency virus, is a preventable disease that weakens the body's immune system. AIDS, or acquired immunodeficiency syndrome, occurs at the most advanced stage of HIV infection. Since the emergence of the HIV epidemic in the early 1980s, legislative approaches have been used by governments to prevent HIV transmission. These laws have often criminalized behaviours and potential exposure to HIV, but with advancements in HIV treatment and prevention, many of these laws are now outdated and in need of modernization. Syringe services programs (SSPs), pre-exposure prophylaxis (PrEP), and antiretroviral therapy (ART) are all effective tools that can help reduce HIV transmission. This raises the question: can laws help reduce HIV transmission and, ultimately, end the HIV epidemic?
| Characteristics | Values |
|---|---|
| HIV prevention laws | Criminalize certain behaviours and potential exposure to HIV |
| Passed based on limited scientific understanding of HIV transmission | |
| Many are outdated due to advancements in HIV treatment and prevention | |
| Some states are considering legislation to modernize and decriminalize HIV | |
| 37 states had laws criminalizing HIV exposure as of 2020 | |
| 24 states require HIV-positive individuals to disclose their status to sexual partners | |
| 14 states require disclosure to needle-sharing partners | |
| 25 states criminalize low or negligible risk behaviours | |
| HIV prevention measures | Antiretroviral therapy (ART) |
| Pre-exposure prophylaxis (PrEP) | |
| Condom use | |
| Syringe services programs (SSPs) | |
| Male circumcision | |
| HIV medicines | |
| Harm reduction strategies | |
| HIV strategies | WHO, Global Fund, and UNAIDS have strategies aligned with SDG target 3.3 to end the epidemic by 2030 |
| EHE (Ending the HIV Epidemic): A Plan for America aims to end the epidemic in the US by 2030 |
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What You'll Learn
Syringe services programs (SSPs)
Nearly 30 years of research show that SSPs are not associated with increased drug use, crime, or syringe litter in communities. In fact, SSPs can play an important role in reducing the transmission of HIV and other infections. They are also beneficial in preventing outbreaks of other diseases, such as hepatitis C, by providing safe disposal of used needles and syringes.
The more syringes distributed per number of people who inject drugs, the more likely used syringes will be disposed of safely. This helps protect the public and first responders from accidental needle stick injuries. SSPs also provide education on overdose prevention and partner with local law enforcement to provide them with naloxone, which can help prevent death in the event of an overdose.
SSPs are an important tool in the effort to end the HIV epidemic by reducing transmission among people who inject drugs. They can also provide an entry point for a range of services to help stop drug use and improve the overall health of communities.
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HIV criminalisation laws
The Impact of HIV Criminalisation Laws
Global Variations
The United States was the first country to introduce HIV-specific criminal laws in 1987, and over half of its states have HIV criminalisation laws with lengthy sentences. However, some states like California and Colorado have modernised these laws recently. Regions like Eastern Europe, Central Asia, and Sub-Saharan Africa have a significant number of countries with HIV criminalisation laws, and women are more likely to be prosecuted in these regions.
Intentional vs. Unintentional Acts
It is important to distinguish between intentional and unintentional acts. Globally, most HIV criminalisation prosecutions involve severe punishment for unintentional or 'reckless' HIV exposure or transmission. The Netherlands stands out as one of the most progressive countries, criminalising only intentional HIV exposure or transmission.
The Way Forward
The high rates of criminalisation persist, despite successful advocacy campaigns in countries like Belarus, which amended its law to remove criminal liability for individuals who disclosed their HIV status and had mutual consent with their partners. To end the HIV epidemic, it is crucial to address factors such as injection drug use, HIV-related stigma, homophobia, and lack of access to prevention, testing, and treatment.
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Antiretroviral drugs (ARVs)
ART is recommended for all patients with HIV by the Department of Health and Human Services (DHHS) and the World Health Organization (WHO). It is a daily treatment of multiple HIV medications, with a typical initial regimen including 3 HIV medications from a minimum of two drug classes. ART is not a cure, but it can reduce the amount of HIV in the body (the viral load) and keep the immune system healthy.
People with HIV who take ART consistently and achieve an undetectable viral load have no risk of transmitting HIV to their sexual partners. This makes ART critical in preventing HIV transmission and improving the health of people living with HIV. ART can also be used to prevent perinatal transmission of HIV from mother to child. Pregnant women with HIV take HIV medicines to protect their own health and prevent transmission during pregnancy, childbirth, and breastfeeding. After birth, babies receive HIV medicine to protect them from any potential infection.
Oral Pre-Exposure Prophylaxis (PrEP) is a type of ARV used as an HIV prevention option for people who do not have HIV but are at high risk of contracting it. When taken before possible exposure to HIV, PrEP can reduce the risk of infection. Similarly, Post-Exposure Prophylaxis (PEP) is used after potential exposure to the virus.
The success of ARVs and ART has reduced HIV to a chronic condition in many parts of the world, as progression to AIDS has become rare. Studies have shown that ART has led to a 60-80% decline in AIDS rates, hospitalization, and death. The World Health Organization (WHO) and other global health initiatives have set targets to end the HIV epidemic by 2030, with goals of achieving 95% diagnosis, treatment, and viral suppression among people living with HIV.
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Access to testing and treatment
The World Health Organization (WHO) and other global health organizations have set targets to end the HIV epidemic by 2030. These targets include ensuring that 95% of people living with HIV know their status, receive antiretroviral therapy, and achieve a suppressed viral load by 2025. As of 2023, significant progress has been made, with 86% of people living with HIV aware of their status, 77% receiving antiretroviral therapy, and 72% achieving a suppressed viral load.
To improve access to testing, some states are considering legislation to allow minors to access HIV testing and treatment without parental consent. Additionally, increasing access to pre-exposure prophylaxis (PrEP) is a key strategy in preventing HIV transmission. PrEP is a daily pill that can help prevent HIV for at-risk individuals, such as those with HIV-positive partners or those who inject drugs. Several states are considering expanding access to PrEP pills, and some states are proposing legislation to allow pharmacists to dispense PrEP under certain conditions.
Syringe services programs (SSPs) are another important intervention to prevent HIV transmission among people who inject drugs. SSPs provide access to sterile injection equipment and can serve as an entry point for a range of services, including treatment for substance use disorders. By providing clean needles and syringes, SSPs can dramatically reduce the risk of HIV transmission associated with unsterile injection equipment. Additionally, medication-assisted treatment for substance use disorders can help address the opioid crisis, which is a significant factor in new HIV infections.
In addition to expanding access to testing and treatment, it is crucial to address the stigma associated with HIV and homophobia, which can hinder people from seeking testing and treatment services. Modernizing state laws to decriminalize HIV transmission and reduce criminal penalties can also help encourage individuals to disclose their HIV status and seek the necessary treatment and support.
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HIV prevention medicines
PrEP is only available by prescription, and those taking it must undergo regular HIV tests, usually every three months, to ensure it is safe for them to continue. It is important to note that PrEP does not protect against other sexually transmitted diseases (STDs) and is not a substitute for safe sex practices.
Another HIV prevention medicine is post-exposure prophylaxis, or PEP. PEP is for emergency situations where an individual has possibly been exposed to HIV. It must be started within 72 hours of exposure and taken daily for 28 days. Similar to PrEP, PEP also requires regular HIV screening and follow-up with a healthcare provider.
The World Health Organization (WHO) and other global health initiatives have set targets to end the HIV epidemic by 2030. These include increasing access to antiretroviral therapy (ART) and HIV medicines, which can help suppress viral loads and prevent transmission to sexual partners. Syringe services programs (SSPs) and harm reduction strategies for people who inject drugs are also crucial in reducing HIV risk and transmission.
Effective interventions and scientific advances have driven down the number of new HIV infections, and there is a renewed focus on areas where HIV transmission is most frequent. However, there are ongoing challenges, such as the opioid crisis and the lack of access to HIV prevention and treatment in certain communities, which threaten to undermine progress.
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Frequently asked questions
More than half of US jurisdictions have laws criminalizing knowing exposure to or transmission of HIV. Twenty-four states require people who are aware that they have HIV to disclose their status to sexual partners, and 14 states require disclosure to needle-sharing partners.
There is little evidence supporting these laws’ effectiveness in reducing HIV incidence. In fact, these laws may undermine prevention efforts outlined in the US National HIV/AIDS Strategy. Criminal laws have not been shown to be effective in reducing rates of HIV infection.
Guidelines for modernizing HIV-related criminal statutes could assist policymakers who wish to reform laws. Substantively, guidelines for modernization should provide draft language that clarifies prohibited acts, eliminates liability for no-risk activities, focuses on intentional and actual transmission, and sets high standards for using scientific evidence in efforts to establish transmission and the risk of transmission.
